This is a lecture by Michelle Munro from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Administration and Management of Pain Medication
Author(s): Michelle Munro (University of Michigan), MS, 2013
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2

3. Administra*on
and
Management
of
Pain
Medica*ons
Ghana
Emergency
Nurses
Collabora6ve
Michelle
Munro,
MS,
CNM,
FNP-­‐BC
February
18,
2013
3

4. Cri*cal
Outcome
• Emergency
nurse
assesses,
iden6fies,
and
manages
acute
and
chronic
pain
within
the
emergency
seHng
4

5. Specific
Outcomes
•
•
•
•
•
•
•
•
•
Define
the
types
of
pain
and
complica6ons
of
pain
management
Delineate
pain
physiology
and
mechanisms
of
addressing
pain
with
medica6ons
Define
the
general
assessment
of
the
pa6ent
in
pain
Delineate
the
nursing
process
and
role
in
the
management
of
the
pa6ent
with
acute
and
chronic
pain
Apply
the
nursing
process
when
analyzing
a
case
scenario/pa6ent
simula6on
Predict
differen6al
diagnosis
when
presented
with
specific
informa6on
regarding
the
history
of
a
pa6ent
List
and
know
the
common
drugs
used
in
the
emergency
department
to
manage
the
painful
condi6ons
and
conduct
procedural
seda6on
Consider
age-­‐specific
factors
Discuss
medico-­‐legal
aspects
of
care
of
pa6ents
with
pain
related
to
emergencies
5

6. Review
of
Classifica*on
• Physiological
– Nocicep6ve
– Neuropathic
– Psychological
• Clinical
– Acute
– Chronic
– Malignant
6

7. Review
of
Pathophysiology
• Pain
– Involves
four
physiological
processes:
• Transduc6on
• Transmission
• Modula6on
• Percep6on
7

8. Review
Ques*on
• What
is
pain????
– Pain
is
whatever
the
experiencing
person
says
it
is,
exis4ng
whenever
he
or
she
says
it
does!
8

9. Focus
on
Acute
and
Chronic
Pain
• ACUTE
PAIN
–
–
–
–
Precipita6ng
event
with
well-­‐defined
pa[ern
of
onset
Warning
signal
that
6ssue
damage
has
occurred
Evidence
of
6ssue
damage
Short-­‐term
(6
months
or
less),
then
pain
resolves
and
normal
func6on
returns
• CHRONIC
PAIN
–
–
–
–
Occurrence
may
not
be
associated
with
an
iden6fied
injury
or
event
No
useful
purpose
aber
diagnosis
is
made
May
not
have
iden6fiable
cause
Long-­‐term
(longer
than
6
months
and
possibly
permanent)
9

10. Acute
Pain
• Signs
and
symptoms
reflect
hyperac6vity
of
the
autonomic
nervous
system
(increased
heart
rate,
blood
pressure,
respiratory
rate,
diaphoresis)
• Behavioral
manifesta6ons
(groaning,
grimacing,
guarding,
wincing,
anxiety)
• Client
reports
pain
• Pain
usually
responds
to
commonly
prescribed
medical
and
nursing
interven6ons
10

11. Chronic
Pain
• Signs
and
symptoms
of
acute
pain
no
longer
present,
indica6ng
adapta6on
of
the
autonomic
nervous
system
• Behavioral
manifesta6ons
include
a
blank
or
normal
facial
expression
• Client
may
not
men6on
pain
unless
asked
• May
be
difficult
to
treat,
unresponsive
to
conven6onal
modali6es,
and
ul6mately
disabling
11

12. Planning
&
Implementa*on
1. Determine
priori6es
of
care
a)
b)
c)
d)
e)
Maintain
ABC
Provide
supplemental
oxygen
IV
access
Obtain
and
set
up
equipment
Prepare/assist
with
medical
interven6ons
-­‐ Treat
underlying
condi6ons
-­‐ Cardiac
&
pulse
oximetry
monitoring
as
needed
f) Provide
measures
for
pain
relief
-­‐
Consider
non-­‐pharmacological
interven6ons
like
posi6oning
(splints,
support
with
pillows,
sling)
&
cutaneous
s6mula6on
(ice,
heat,
massage)
g) Administer
pharmacological
therapy
as
ordered
12

13. Planning
&
Implementa*on
2. Relieve
anxiety
and
apprehension
3. Allow
significant
others
to
remain
with
pa6ent
if
suppor6ve
4. Educate
pa6ent
and
significant
others
• About
the
efficacy
and
safety
of
opioid
analgesics
13

14. Interven*on:
Administer
Pharmacological
Therapy
as
Ordered
The
World
Health
Organiza6on
(WHO)
recommends
the
use
of
the
analgesic
ladder
as
a
systema6c
plan
for
the
use
of
analgesic
medica6ons.
Step
1:
Use
nonopioid
analgesics
for
mild
pain
Step
2:
Adds
a
mild
opioid
for
moderate
pain
Step
3:
Use
of
stronger
opioids
when
pain
is
moderate
to
severe
14

15. WHO
Analgesic
Ladder
World
Health
Organiza6on
15

16. Expected
Outcomes
for
the
Client
With
Acute
Pain
• Provide
relief
using
pharmacological
and
nonpharmacological
interven6ons
to
achieve:
– Decreased
anxiety
– Client
verbaliza6on
of
planned
analgesic
interven6ons
– Decreased
verbal
complaints
and
behaviors
that
indicate
unrelieved
pain
– Decreased
need
for
analgesic
interven6ons
– Tissue
heals
16

17. Expected
Outcomes
for
the
Client
with
Chronic
Pain
• Set
realis6c
goals
with
client
and
family
• Reduce
pain
to
a
level
that
the
client
can
tolerate
• Ac6vely
involve
the
client
in
the
treatment
regimen
• Maximize
the
client’s
quality
of
life
17

18. Interven*ons
to
Manage
Acute
Pain
•
•
•
•
•
•
Selec6ng
analgesics
Titra6ng
the
dosage
Choosing
a
schedule
Iden6fying
the
appropriate
route
Trea6ng
procedural
pain
Planning
across
the
con6nuum
of
care
**Acute
pain
from
surgery,
diagnos6c
procedures,
and
trauma
is
underes6mated
and
undertreated!
18

19. Interven*ons
to
Manage
Chronic
Pain
• Developing
a
therapeu6c
rela6onship
• Partnering
with
the
client
and
family
• Involving
a
mul6disciplinary
team
• Using
mul6ple
modes
of
therapy
19

20. Evalua*on
and
Ongoing
Monitoring
1. Con4nuously
monitor
and
treat
as
indicated
-­‐
-­‐
-­‐
-­‐
-­‐
Level
of
consciousness
Hemodynamic
status
Breath
sounds
and
pulse
oximetry
Cardiac
rate
and
rhythm
Pain
relief
2. Monitor
pa4ent
response,
outcomes,
and
modify
nursing
care
plan
as
appropriate
3. If
posi4ve
pa4ent
outcomes
are
not
demonstrated,
reevaluate
assessment
and/or
plan
of
care
20

21. Documenta*on
• Before
and
aOer
interven6on
document:
– Vital
signs
• Temperature
• Heart
Rate
• Pulse
• Respira4on
Rate
– Pain
Score
– Pa6ent
response
21

22. Age
Related
Concerns
1. Pediatrics:
Growth
or
Development
Related
• Children’s
pain
tolerance
increases
with
age
• Children’s
developmental
level
influences
pain
behavior
• Localiza6on
of
pain
begins
during
infancy
• Preschoolers
can
an6cipate
pain
• School
age
children
can
verbalize
pain
and
describe
loca6on
and
intensity
22

23. Pediatrics
“Pearls”
• Children
may
not
admit
to
pain
to
avoid
an
“injec6on”
• Distrac6on
techniques
can
aid
in
keeping
the
child’s
mind
occupied
and
away
from
pain
• Opioids
are
no
more
dangerous
for
children
than
for
adults
23

24. Age
Related
Concerns
2. Geriatrics:
Age
related
• Pain
is
not
a
normal
aging
consequence
• Chronic
pain
alters
the
person’s
quality
of
life
• Chronic
pain
may
be
caused
by
a
myriad
of
condi6ons
24

25. Interven*ons
to
Manage
Pain
in
the
Older
Adult
• The
use
of
analgesics
in
general
is
not
impaired
by
normal
aging,
but
the
older
adult
is
at
greater
risk
for
analgesic
toxicity
– Physiological
variables
cause
slower
metabolism
of
analgesics
– Nonopioid
analgesics,
acetaminophen,
and
NSAIDs
are
used
to
provide
relief
for
mild-­‐to-­‐moderate
pain
at
a
decreased
dosage
– Opioids
can
be
used
for
moderate-­‐to-­‐severe
pain
but
are
more
likely
to
cause
side
effects
25

26. Geriatric
“Pearls”
• Adequate
treatment
may
require
devia6on
from
clinical
pathways
• Administer
pain
relieving
medica4ons
at
lower
dose
and
increase
slowly
26

27. Barriers
to
Effec*ve
Pain
Management
1. AHtudes
of
emergency
health
care
providers
2. Hidden
biases
and
misconcep6ons
about
pain
3. Inadequate
pain
assessment
4. Failure
to
accept
pa6ents’
reports
of
pain
5. Withholding
pain-­‐relieving
medica6on
6. Exaggerated
fears
of
addic6on
7. Poor
communica6on
27

28. Improving
Pain
Management
• Changing
aHtudes
• Con6nuing
educa6on
related
to
the
reali6es
and
myths
of
pain
management
• Evidence-­‐based
prac6ce
• Cultural
sensi6vity
28

29. Focus
on
Procedural
Seda*on
• The
Joint
Commission
(TJC)
has
standard
defini6ons
for
four
levels
of
seda6on
and
anesthesia:
1. Minimal
seda6on
2. Moderate
seda6on/analgesia
3. Deep
seda6on/analgesia
(pa6ent
not
easily
aroused)
4. Anesthesia
(requires
assisted
ven6la6on)
29

30. Preparing
for
Procedural
Seda*on
• Indica4ons
– Suturing
– Fracture
reduc6on
– Abscess
incision
and
drainage
– Joint
reloca6on
30

31. Preprocedural
Evalua*on
• Assessment
– Medical
history
•
•
•
•
•
Major
organ
systems
Anesthesia
and
seda6on
Medica6ons
Allergies
Most
recent
oral
intake
• Focused
Physical
Exam
– Heart
– Lungs
– Airway
– Laboratory
tes6ng
as
indicated
based
on
underlying
condi6on
31

32. Pa*ent
Counseling
• Pa6ent
should
be
counseled
on
the
risks,
benefits,
limita6ons,
and
alterna6ves
of
the
procedural
seda6on
and
analgesia.
32

33. Preprocedural
Fas*ng
• For
elec6ve
procedures,
should
be
sufficient
6me
allowed
for
gastric
emptying
(1-­‐2
hours)
• For
urgent
or
emergent
situa6ons,
the
poten6al
for
pulmonary
aspira6on
should
be
considered
when
determining
target
level
of
seda6on,
delay
of
procedure,
or
protec6on
of
the
trachea
by
intuba6on
33

34. Monitoring
• The
following
should
be
recorded
before,
during,
and
aber
the
procedure
– Pulse
oximetry
– Response
to
verbal
commands
– Pulmonary
ven6la6on
(observa6on,
ausculta6on)
– Blood
pressure
and
heart
rate
at
5-­‐15
minute
intervals
unless
contraindicated
– ECG
for
pa6ents
with
significant
cardiovascular
disease
34

35. Emergency
Equipment
that
should
be
available
during
procedural
seda*on
•
•
•
•
•
Suc6on
Airway
equipment
Intravenous
equipment
Pharmacologic
antagonists
Basic
resuscita6ve
medica6ons
35

36. Poten*al
Dangers
During
Procedural
Seda*on
•
•
•
•
•
•
Aspira6on
Respiratory
Depression
Cardiovascular
Complica6ons
Inadequate
Seda6on
Nausea
&
Vomi6ng
Pa6ent
dissa6sfac6on
36

37. Procedural
Seda*on
• Review
of
Procedure:
– Baseline
vital
signs
and
level
of
consciousness
– Explain
procedure
to
pa6ent
and
family
– Obtain
venous
access
– Equipment:
cardiac
monitor
if
indicated,
blood
pressure
monitor,
pulse
oximeter,
suc6on,
oxygen
equipment,
endotracheal
intuba6on
equipment,
IV
supplies,
reversal
agents
– Assist
with
medica6ons
– Maintain
con6nuous
monitoring
during
procedure
– Document
vital
signs,
level
of
consciousness,
and
cardiopulmonary
status
every
5-­‐15
minutes
(depending
on
level
of
seda6on
and
ins6tu6onal
policies)
– Post-­‐procedure
discharge
criteria
37

38. Discharge
Criteria
• Usually
discharged
aber
2
hours
(if
planned
outpa6ent
procedure);
otherwise
would
depend
on
pa6ent’s
condi6on
and
ins6tu6onal
policies
• For
out-­‐pa6ent
discharge,
want
pa6ent
to
meet
the
following
criteria:
– Alert
and
oriented
– Vital
signs
stable
– Baseline
ambula6on
status
achieved
– Pain
and
nausea
well
controlled
38

39. Review
Ques*on
• Describe
the
three
steps
of
the
WHO
Analgesic
Ladder.
39

40. Answer
World
Health
Organiza6on
40

41. Review
Ques*on
• What
must
be
considered
when
trea6ng
the
older
adult
with
pain?
41

42. Answer
– Physiological
variables
cause
slow
metabolism
of
analgesics
– Nonopioid
analgesics,
acetaminophen,
and
NSAIDs
are
used
to
provide
relief
for
mild-­‐to-­‐moderate
pain
at
a
decreased
dosage
– Opioids
can
be
used
for
moderate-­‐to-­‐severe
pain
but
are
more
likely
to
cause
side
effects
– Administer
pain
relieving
medica4ons
at
lower
dose
and
increase
slowly
42

43. Case
Review
• Discuss
a
nursing
care
plan
and
appropriate
pain
management
for
the
following
scenario:
– A
40
year
old
woman
appears
at
the
A
&
E
with
complaints
of
pain
in
her
ankle.
She
suffered
a
trauma
to
her
ankle
in
which
she
fell
down
in
a
hole.
Her
examina6on
reveals
a
fracture
and
she
will
need
cas6ng
but
in
the
mean6me
she
is
need
of
pain
management.
Her
temp
is
37.5oC,
Pulse
is
105,
Respira6ons
are
22,
B/P
is
116/70.
• Assessment:
General
assessment
for
pain
would
include
what
indicators?
• Nursing
diagnosis:
What
do
you
think
is
going
on?
• Plan/Interven*on:
What
type
of
nursing
plan
would
you
implement?
What
type
of
pain
medica6ons
should
be
ini6ated?
• Evalua*on:
How
oben
would
you
follow-­‐up
with
pa6ent?
What
risks/
complica6ons
would
you
be
looking
for?
43

44. Ques6ons
Dkscully (flickr)
44